Seizure Questionairre
Patient Name
First Name
Last Name
Date of First Seizure (Approximate if not known)
*
-
Month
-
Day
Year
Date
Total Number of Seizures Since Onset
*
If onset was more than a month ago, what is approximate number of monthly seizures exhibited
Is the pet responsive to you during the event?
*
Yes
No
Does the pet urinate during the event?
*
Yes
No
Does the pet salivate during the event?
*
Yes
No
Is there a period of confusion and or weakness and or wobbliness after the event?
*
Yes
No
Do you have a video of any of the events?
*
Yes
No
Option to Upload the Video
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How long do the seizures usually last?
*
Are there any known triggers for the seizures?
*
Are there any changes in the pet's behavior in between the seizures? Please describe if yes.
*
Has the pet been diagnosed with any other neurological condition including previous head trauma? Please describe if yes.
*
Current medications administered including supplements but not including flea / tick medications?
Drug Name
Dose if known
How frequently administered?
How long has the medication been given?
Drug #1
Drug #2
Drug #3
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